As we travel throughout this country providing documentation lectures to our physicians and clients, the most frequently asked questions are those concerning Critical Care documentation. Immediately when the physicians hear those words they crumble into a dearth of confounding confusion, and justifiable rage.
‘We’ve heard this lecture before and we still don’t get it!’ They know it is important because its lots of money lost. They have to listen to this menagerie of ifs, ands, & buts courtesy of the CMS abundant rules, exceptions and diverging scenarios committee.
Just minutes later after this learning session, it flies out of this perpetual anatomy class once again, only to be confused again the next time they see a critical care patient throwing up blood in their face and screaming in pain. Trust me, they would rather relearn the anatomical intricacies concerning the entanglement of the brachial plexus that controls the little finger or find the lost Ark of the Covenant than hear this lecture again.
So, with great consternation, we are about to divulge into one case study, yes I said one example, to explain every rule, regulation, outlier, and standard deviation that exists in creation of the black hole of critical care. But prior to that we are going to explain WHY we even want to learn this example; Fore not the reasons that are about to be proclaimed you probably would not care.

“ You need to tell a story in the chronological order of who, what, when, and where did the patient become sick or injured, and share what you did in detail.”

TELL THE PATIENT’S STORY
We all have had great teachers in our professional career, and we recall many of the facts to this day. Mine was an internal medicine oncology professor who obviously knew a lot about medicine. After reading my hand­written history and physical examination, he said one thing I’ll always remember:
“You know, Dr. Orcutt, you have all the parts to the history and patient exam, but you have not told the Story. I asked “What do you mean?” “You need to tell a story in the chronological order of who, what, when, and where did the patient become sick or injured, and share what you did in detail how you attempted to intervene in the process no matter the outcome of the patient.” This really stuck with me.

UNDERSTAND THE FINANCIAL IMPACT OF CRITICAL CARE
Physicians must to be willing to address their critical care documentation. The impact of the lack of information in a patients chart cost your group and hospital revenue. Not to mention the chart is incomplete. For an emergency group serving 52,000 patients a year the loss of revenue one million dollars to the group.
Many physicians also do not completely understand what qualifies for a critical care, such as a child arrives with very severe asthma and a low pulse ox and after aggressive treatment is later sent home. They ask, how is it critical care if you discharge the patient?
The physician did not completely under- stand the CMS definition: In Internal Medicine/Emergency Medicine/ Critical Care Medicine Residency, Critical Care has been defined as the delivery of medical care to “any patient who is physiologically unstable, requiring constant and minute- to-minute titration of therapy according to the evolution of the disease process.”
As defined by AMA CPT 2018, a critical illness is an “illness or injury [which] acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition.”
The CMS definition uses more stark verbiage, such as “imminent,” “high probability,” and “life-threatening deterioration.” Of course, you should use these in your patient documentation, but this sounds like a patient that has already slipped and halfway down the grave.
This is confusing to many physicians because some don’t remember that applying emergent care to a declining organ system disease is a critical care intervention, even when they are preventing the acute, near-death experience in the patient.
This is one of the two most critical areas of the report to dictate very specifically. Most of you have voice dictation. Get precise! I will discuss much more in the next article about what you should say and report.
The second is in your medical decision-making documentation This has become the hottest topic in emergency medicine reimbursement.

CLINICAL PRESENTATION #1
An 80-year-old man enters the emergency room with his wife after going to a movie and said “I think I ate some bad popcorn. I feel nauseated and bloated in the lower part of my stomach and it’s worse when I walk.”
Triage discovers all VS are normal, he has a history of a quadruple bypass surgery, and elevated cholesterol. After waiting 5 minutes the patient is taken to bed 24, and when he climbs onto the gurney he collapses in pain and the monitor displays a pressure of 60mm/Hg and pulse of 135 with diaphoresis. The nurse calls for help, and the ED physician, Dr Yong and staff run into the room.
Initial exam reveals an elderly male writhing with severe abdominal pain with bright red blood coming from his stool. Simultaneously multiple IV’s and a central line are initiated, labs and type specific blood is ordered, along with boluses of NS. Bedside US is used to investigate the issue and discovers the patient has an aortic aneurysm dissection with attached small bowel as the patient arrests. CPR is begun and a code blue is called as the patient is intubated. After five minutes the patient has a pulse pf 60 and BP of 70 and was emergently sent to the OR at 0015 hrs. The physician documents a critical care time of 47 minutes in his report not including procedures that did not qualify and not the few minutes of CPR which is a separate billable intervention...
This patient has examples of some of the intricacies of critical care documentation. Clearly the patient diagnostically qualifies as a critical care level of service 99291 because of the critical nature of his presentation, and the multiple critical diagnoses listed.
The total time of duration of Critical Care with the many procedures and interventions that occurred with this patient in a very short period of time. There are certain procedures that are included with 99291 that are Not separately billable, and these procedures are considered to be included with this code.

AFTER MIDNIGHT/SECOND DAY BILLING OF CRITICAL CARE?
One interesting fact in this case is the patient stayed in the ED until the next calendar day after midnight.
Can you bill a second critical care on the next day? In regard to disrupted (non-continuous) Critical Care that occurs after mid- night, your provision of all such Critical Care is considered new for the post-midnight date and should be reported separately You can perform a second CC billing ONLY if he was stabilized before midnight and then after midnight he succumbs to a Second critical event such as if he develops ventricular fibrillation after midnight.

CLINICAL PRESENTATION #2
A 63-year-old gentleman was brought to the University ED after collapsing while watching a football game. He has a history of syncopal episodes, a recent MI and takes a beta blocker for mild hypertension.
VS: BP 97/60, Pulse 43, Temp 98.6 and is alert and cooperative.
Patient is placed in a monitor bed, an EKG is produced and given to the second-year resident. It then appears the patient is developing a new bifasicular heart block from his recent MI.
The resident performs a rapid history and exam, knowing this type of block with the recent MI can be deadly. Ten minutes after patient arrival, she seeks advice from her attending physician; he agrees this patient can easily deteriorate and recommends a trans-venous pacemaker placement stat. The resident concurs and the attending will monitor the trans-venous pace-maker insertion.
The resident monitors the patient at the bedside for a total 35 minutes in unstable condition. Now the patient is worsening with the pulse at 38 and a palpable BP of
55. The resident orders several intravenous medications to address the BP and pulse rate. Now the ED physician is ready for pacemaker insertion.
The attending rushes over and monitors the entire procedure without teaching, and the entire event lasts for 20 minutes. The patient’s heart is captured by the pacemaker lead, and he obtains a pulse of 80 and a BP 90. The patient is admitted to the CCU for further care.
The attending writes a note in the record stating. “Patient developed hypotension and profound bradycardia; I spent 45 minutes with the patient providing fluids, pressers, and oxygen and transvenous pacemaker insertion. I reviewed the resident’s documentation and procedure, and I agree with the resident’s assessment and plan of care.”